Medication Administration Essay


Always the goal of treatment by using drugs is to giving the patient the best therapeutic benefit and improve the patient’s life as well as to cut the possibility exposing the patient to some of the dangers resulting from the use of some drugs and commit errors that associated to treatment with drugs may occur from all the medical team members from doctors, pharmacists, nurses, technicians and others without exception, regardless of their level of scientific, whether they are the owners of long experience or limited and often medication errors occur without being detected or without being reported and documented or hide or cover them up.Medication Administration Essay


We can be defined the medication errors as (any event caused by medication error or give the wrong way may result in harm to the patient or not taking place so that the damage could be avoided if it was given the right medicine for the patient in the right way). Of the most common errors made by pharmacists is trying to explain the instructions unclear more than an attempt clarification from the doctorMedication Administration Essay

And sometimes pharmacist’s colleagues asking them, you should ask your doctor so as not to mistake again.
There are some Types of medication errors that we should know it. Errors in the prescription: This error occur when the wrong drug is for writing (prescription), the prescription maybe unclear terms of error , or the medication or dosage, or with a table or repeat doses. Errors in copying the recipe: This error occurs during the copy command in the pharmaceutical drug administration record Medication Administration Record MAR. The error is find in the back or on the patient’s name or by medication or use a table or repeat doses.Medication Administration Essay Errors in the distribution and dispensing medicine: This error occurs from the beginning of the pharmacy where the medication preparation, it was wrong to send the drug to the wrong patient, or sends medication error occurs, or in the wrong dose or sent by use, or in the table of repeat doses happens. Errors in administering medication: This error occur during the process of giving the medicine to the patient, the error is when you give medicine to another patient, or given the wrong medicine, or the wrong dose, or through the use of, or schedule a repeat doses, or may forget to give the medicine already happening.Medication Administration Essay In addition to the obvious problem in the writing of the prescription is a clear line of responsibility for the complete write your doctor and

Pharmacist must be achieved to complete the prescription with instructions.
To protect children from occur medication errors at home:
• Tell the doctor about any medication intake your child at home and includes all types of vitamins and herbs.
• Tell your doctor or pharmacist if you breastfeed breastfeeding as some medications transmitted to the child through breast milk and may cause damage to the child.Medication Administration Essay
• Tell your doctor or pharmacist about any allergy medicines for the child type to prevent giving the child any medication may cause damage to him.
• Knowledge of the current weight of the child as the drug dose is calculated according to the weight of the child.
• Do not give your child any medication or any alternative treatment from a doctor is not aware of, to prevent any error in the quality or dose of any medication or drug reactions may cause harm to the child.Medication Administration Essay

• Make sure when you receive treatment from a pharmacy dedicated to your child to prevent receiving treatment for another child by mistake.
• Ask your pharmacy for some information related to treatment, such as:
◦ The medicine’s name .
◦ The reasons of medication use.
◦ Add times taking this medicine and duration.
◦ what is a side effect of this drug.
◦ The method of drug store.
• Ask your pharmacist for written information on how to use and duration of treatment without clarity.
• If the exchange different treatment from the previous user of the treatment is to tell you by your doctor, ask your pharmacist to make sure that an error occurs.Medication Administration Essay
• Do not use the normal dose to measure liquid medicine kitchen spoons and use the measuring spoons attached own medicine

In sum up, mismanagement is considered in the use of the drug a major cause of harm to the patient’s medication errors.
There are a realistic understanding of the frequency and the results of medication errors, and there is also a realistic understanding necessary to make use of medications safer steps. Pharmacists contribute through their service and their attention is very important and effective part in the reduction of adverse incidents to the drug, and their understanding of the mechanism of error and how to avoid them, it happens to occur, the vital role in ensuring the safety of their patients. Must at all pharmacists working in the field of health care work for a common goal of improving the service provided to patients and the control and limitation of the study of the root causes of medication errors to access and thus correct the wrong practices and develop approaches to reduce them and prevent their occurrence in the future.Medication Administration Essay

Medication Administration The intended use of medications is meant to improve a person’ health, it is very important the individual administering medication or self-medicating use the drugs correctly, by following the doctors’ instruction for the medication prescribed. Medication is given to diagnose, treat, and prevent illness. Medication can be very dangerous, which can potentially cause harm or even deaf if it’s not used properly.
Administering medication requires the understanding of how the medication is to enter the body such as orally, transdermal, or intravenous.Medication Administration Essay It also requires the knowledge of when the medication needs to be administered, the possible side effects, and its toxicity. Doctors, nurses, and a few other…show more content…
According to the Food and Drug Administration (FDA 2009), the wrong route of administrating medication accounts for 1.3 million injuries each year. An article published in September issue of the Journal of Patient Safety estimates there are between 210,000 and 400,000 deaths per year associated with medical errors. This makes medical errors the third leading cause of deaths in the United States, behind that comes heart disease and cancer.Medication Administration Essay To prevent medical errors always follow the Three Checks and most importantly the Rights of Medication Administration. The “Rights of Medication Administration” helps to ensure accuracy when administering medication to a patient. When administering medication the administer should ensure they have the Right Medication, Right Patient, Right Dosage, Right Route, Right Time, Right Route, Right Reason, and Right Documentation. Also remember the patient has the right to refuse, assess patient for pain, and always assess the patient for signs of effects.Medication Administration Essay

Medication management is one of the major responsibilities of a nurse leader/manager in any
health care setting particularly in nursing homes (Health Information and Quality Authority
(HIQA) 2009). It is a complex process which involves different phases including prescribing,
transcribing, ordering, dispensing, supplying, administering and storing (Dilles et al. 2011).Medication Administration Essay
Evidence suggests that at each phase of the cycle, error do occur adversely influencing
patients’ safety, which is a priority in today’s nursing practice (Pronovost et al. 2005).
Additionally, Tumheim (2003) concluded that adverse drug events are common in nursing
homes, and nursing home residents are vulnerable to such events due to a high incidence of
polypharmacy and changed pharmacokinetics and pharmacodynamics. ‘The latter issues refer
to age-related changes in the functions and composition of the human body, which require
adjustments of medication selection and dosage for elderly individuals’ (Dilles et al. 2011,
p.172). According to Choo et al. (2010), medication errors are one of the most common types
of medical errors that occur in healthcare institutions. They further state that morbidity from
medication errors results in high financial costs for health care institutions and adversely
affects the patient’s quality of life. Medication errors have also been identified as the most
common single preventable cause of adverse events (National Medicines Information Centre,
In practice, nurses have been trained to practice the five rights of medication administration,
namely, the right medication, right dose, right route, right time and right patient but evident
suggests that although the five rights ‘provide a useful checking ritual, they focus on the
individual nurse’s performance during the final stage of medication administration and
do not reflect the responsibility and accountability associated with medication administration
or multidisciplinary approaches to medication management’(Choo et al, 2010, p.854).
Therefore it was proposed that additional strategies should be implemented to prevent and
reduce medication error (William, 2007).Medication Administration Essay
In this chapter, the writer will focus on the aim and objectives of the change project and the
rationale for carrying out the change.
1.2 Aim and objectives
The aim of this project was to implement best practice in medication management in a
nursing home and the objectives were to reduce medication errors/adverse drug events
through incident reporting and adherence to medication administration safety guidelines (nine
rights of medication administration); to promote the safety of the residents and comply with
professional and national standards on medication management.
1.3 Rationale for carrying out the change
Under the Health (Nursing Homes) (Amendment) Act (Health Act) (2007), all providers and
social care services including private, public and voluntary sector have to register with HIQA
if they undertake regulated activities as defined in the Act . This prompted a recent
unannounced inspection of the writer’s health care setting by HIQA, many recommendations
were made to ensure that the provider/person in charge (nurse manager/leader) comply with
the Health Act 2007 and National Quality Standards for Residential Care Settings for Older
People in Ireland prior to being registered. These recommendations involve change in
practice, structure and systems of the organization. This is congruent with Donabedian (2003)
who state that quality is a function of three domains: structure, process and outcome.
Structure relate to the conditions under which care is provided, including material resources,
human resources, and organizational characteristics (Donabedian 2003). Process refers to the
activities that constitute health care, including diagnosis, treatment, rehabilitation, prevention,
and patient education (Donabedian, 2003). Finally, outcome relate to changes in individuals
and populations that can be attributed to health care, including changes in health status,
changes in knowledge, changes in behavior, and satisfaction with the care received and its
outcomes (Donabedian, 2003).Medication Administration Essay
However, given the importance of medications in the care of the residents in nursing homes
(HIQA, 2009), errors in medication are taken seriously by the Inspectors. Thus, medication
management was one of the identified priority areas for further improvement in the writer’s
organization. Additionally, the An Bord Altranais (ABA) in an attempt to assist nurses to
understand their roles and responsibilities in medication management prepared a guideline
titled ‘guidance to nurses and midwife on medication management’ (ABA, 2007). The
guideline was also ‘written to enable nurses to reflect on the key points associated with
medication management and the related principles, and thus support effective, safe and
ethical practice’ (ABA, 2007, p.5).Medication Administration Essay
Therefore, the rationale for carrying out this project were as follows: (1) the writer being the
person in charge, a nurse and manager/leader of the organization is ultimately responsible to
ensure medication management is in line with best practice (HIQA, 2007; ABA, 2007) ; (2)
medication management is particularly important in older people as they are extremely
vulnerable to adverse effects of medication (Kosh et al. 2010); (3) the topic chosen is in line
with the guideline for project dissertation published by the Royal College of Surgeons in
Ireland; (4) the proposed change is linked to real problems that are understood by all
stakeholders (Pearce, 2007); (5) the change being implemented is in agreement with strategic
plan and goal of the organization (Cervone, 2011) i.e. obtain registration to operate.Medication Administration Essay
1.4 Summary
Medication management in nursing homes is complex and older people living in such settings
are potentially at risk of medication error than other groups. This error could result in adverse
drug event leading to morbidity and mortality. It is therefore required that all nursing homes
put a system in place to prevent medication error prior to being registered.Medication Administration Essay
This change project was carried out to reduce medication error, promote safety culture and
ensure compliance with both professional and national standards on medication management.Medication Administration Essay

Chapter 2
Literature review
2.1 Introduction
According to Dille et al. (2011), research on medication management in nursing homes is
uncommon and most studies are limited to the stage of medication administration and do not
address other stages of the medication process. However, in order to carry out a broader
search of relevant literature on this change topic, the Royal College of Surgeon in Ireland
(RCSI) library resources was used mainly Science Direct, OVID, CINAHL, Wiley and
Emerald. Other resources used include Google Scholar and INMO (Irish Nursing and
Midwifery Organization) library.Medication Administration Essay
The search term used include: medication safety, medication errors and nursing homes,
adverse drug event, private and public nursing homes, medication management and older
adult. The criteria of selection include the original research article or a systematic review
article. Both English and non English journal articles were included in the selection. Thus,
the following themes emerge:
2.2 Nursing homes in Ireland
Nursing home also referred to as long-term, aged or skilled care facility, have an important
role in the provision of care for dependent older people (Spilsbury et al. 2011). It was
described by Buccheri et al, 2010, p.1367) as a ‘residential facility for persons who require
nursing care and related medical or psychosocial services’. Du Moulin et al (2010) described
it ‘as long-term care facilities that offer 24-h room, board, and health
care services, including basic and skilled nursing care and, for example, rehabilitation or
therapies’ (p.289). In Ireland, nursing homes are referred to as designated centre or residential
care setting (HIQA, 2009). According to a report published by HIQA (2012), there are
currently 574 designated centres for dependent persons in the sector, classified by provider
type as follows: private – 387 (68%), voluntary – 64 (11%) and public – 123 (21%). All
nursing homes (private, voluntary and public) are regulated under the Health Act (2007). The
Department of Health and Children (DoHC) (2006) estimated that 4.3% of people over the
age of 65 were resident in nursing homes, i.e., approximately 19,500 patients of 456,000 and
postulated that if this percentage remain constant as the population in Ireland ages, by 2051
the number in care will exceed 60,000. In contrast, approximately 1.6 million elderly and
disabled persons receive care in 1 of the 17,000 nursing homes in the United States (Jones et
al. 2009). In addition, a survey of 10 developed countries found projected increases in the
percentage of the elderly population from 35% to 99% by 2025, with between 2% and 14.5%
of elderly people residing in some form of long-term care setting (Ribbe et al. 1997).Medication Administration Essay
In recent years, nursing homes are becoming increasingly responsible for the management
of an ever wider range of complex nursing and medical conditions and various initiative have
been developed to improve quality of care delivered to the residents such as educating staff
and introducing care protocols, but despite this, there is still need for further improvement in
the quality of care provided (Du Moulin et al. 2010).
2.3 Medication management in the nursing home sector
Managing medication is a regulated activity under the Health Act (2007) and all registered
nurses (staff nurses and nurse managers) have a duty to protect the residents against risks
associated with management of medication (HIQA, 2009).
Medication management is defined as ‘the facilitation of safe and effective use of
prescription and over-the-counter medicinal products’ (Bulechek and McCloskey, 1999 cited
in ABA 2007, p.53). It is a complex process involving different phases, namely, procurement
(the acquisition and storage processes used by institutions); prescribing (the point that
involves a licensed prescriber issuing a prescription or medication order); transcribing/
documenting(a point that involves the act of transcribing an order or documenting procedures
or anything pertinent to the resident in the notes or on the resident’s chart); dispensing (this
involves the pharmacist’s assessment of the prescription or order and the release of the
product for use by the health care provider or the resident); administering (this encompasses
the act of preparing and providing the medication to the resident using the five rights of
which nurses are aware and is a guiding principle intended to avert errors); monitoring (an
inter- disciplinary approach in evaluating, scrutinizing, and recording the resident’s response/
reaction to the medication administered) (Hicks et al. 2008). According to Mrayyan et al.
(2007), errors can occur in all stages of the process and different professionals can be
involved -physicians, pharmacists and nurses (Figure 1).
US pharmacopeia (2004, Figure 1)
2.4 Medication error
In nursing homes, approximately 19% of all administered medication doses are associated
with medication error (Barker et al. 2002). Preventable adverse drug events occur at a rate of
approximately 1 per 100 resident-months, with more than 60% of these events considered to
be fatal, life threatening, or serious (Gurwitz, 2000). Medication error is any preventable
event that may cause or lead to inappropriate medication use or patient/resident harm while
medication is in the control of the health care professional, patient, or consumer. Such events
may be related to professional practice, health care products, procedures, and systems
including prescribing; order communication; product labelling, packaging, and
nomenclature; compounding; dispensing; distribution; administration; education;
monitoring; and use (National Coordinating Council for Medication Error Reporting and
Prevention, 2007,p.1).Medication Administration Essay
2.5 Adverse drug events
An adverse drug event could be described as ‘preventable mistakes in prescribing and
delivering medication to patients such as prescribing two or more drugs whose interaction is
known to produce side effects, or prescribing a drug to which the patient is known to be
allergic’ (Department of Health and Children (DoHC) 2008, p.42). ‘Studies of adverse events
in numerous countries around the world demonstrate that between 4% and 16% of patients
admitted to hospital experience one or more adverse events, of which up to half are
preventable’ (DoHC 2008, p.2). Some medication errors can lead to adverse events. An
adverse event attributable to medication error is a “preventable adverse event” (Institute of
Medicine, 2000, p. 28). Among the most common adverse events reported internationally are
adverse drug events. A study by the Agency for Healthcare Research and Quality (AHRQ) in
the United States found that adverse medication events caused one out of five injuries or
deaths per year to patients in the hospitals that were studied (Leape et al, 1991).Medication Administration Essay
Much research is being carried out internationally to categorize preventable adverse
drug events and to develop methods to prevent them. The Prescription for Change series,
published in the US in 2000 (Clinical Initiatives Centre, 2000), evaluated the efficacy and
cost of practices to improve medication safety in the hospital setting. The most effective,
least expensive strategies are pharmacy-managed protocols and pharmacist interview
(admission history taking or checking by a pharmacist), dispensing protocols (involving
double checks at nearly all points in process), dedicated observers (observational studies
to check accuracy of administration) and pharmacist order entry. At greater expense,
recommended strategies are: computerised prescribing, code reconciliation (medication
scanned against prescription), automated dispensing systems (pharmacy robots dispense
In Ireland, data on medication error and adverse drug reactions in four hospitals recorded 510
events/near-misses in a three-month period (Kirke et al. 2007). The most common
event/near-miss types were wrong dose, frequency/rate and dose/drug omission, with
monitoring, omission and wrong frequency/rate being the most common categories for
adverse drug events i.e. resulting in patient harm. Seven per cent of the reports involved
patient harm due to adverse drug reactions or medication error (DoHC, 2008).
2.6 Types and causes of medication error
Medication errors in nursing homes are very common due to the fact that nursing home
residents receive more medications than patients in other healthcare settings putting them at
risk of medication related error (Hansen et al. 2010). Although, studies reviewing the type
and causes of medication error in nursing homes are limited, evidence is available in other
settings and these could be applied to nursing homes (Hodgkinson et al. 2006).
According to William (2007), medication errors could be classified according to the stage of
the medication management cycle in which they occur, namely, prescribing errors, dispensing
errors, administration errors, and transcribing errors. A prescribing error includes prescribing
a wrong drug for a patient as well as the wrong dose, quantity and indication,
and prescribing a contraindicated drug (Williams, 2007). Prescribing errors occur in 0.4% of
prescriptions, and happen as a result of inadequate knowledge of the patient
and his/her clinical condition, inadequate knowledge of the drug, calculation errors, illegible
prescriptions, drug name confusion, dosage formulation, use of abbreviations, use of
zero and decimal points, unusual routes of administration, uncommon/complicated dosage
regimens and poor history taking (DH, 2004). Dispensing errors occur when there is a
deviation from the drug prescribed as a result of drug name confusion, failure to clarify an
ambiguous or illegible prescription, similar packaging or single checking (DH, 2004).
According to Dickens (2007), an administration error is an error that results in a patient
receiving a drug other than that intended by the prescriber or when a medication reaches the
patient in a form, dose or strength other than that planned by the prescriber or is administered
at the incorrect route or wrong time. He stated further that an administration error can also
take the form of omission of medication without a valid or error in documentation for
example failure to document that a medication has been given. In addition, Drach-Zahavy
and Pud (2010) defined medication administration error as ‘any deviation from procedures,
policies and/or best practices for medication administration’ (p.794).Medication Administration Essay
It is estimated that administration errors on hospital wards involve around 5% of doses and
occur when the drug administered to the patient is not what was intended by the
prescriber (Williams, 2007; DH, 2004). This type of error could result from errors in other
phases of medication management such as selection, procurement, storage, prescribing,
ordering and transcribing (The Joint Commission, 2007). Alternatively, they may occur as a
consequence of individual or system issues which include poorly written orders, calculation
errors, inadequate space for charting and documentation, lack of sufficient knowledge about
the residents, lack of knowledge about medications, confusion with names of medicines,
interruptions, deviation from policies and procedures, type of administration system, nursing
shortage, small medication rooms, poor lighting, long working hours and inadequate training
(Brady et al 2009; Mrayyan et al 2007; Fontan et al 2003).
Frequent causes of medication administration errors are illegible prescriptions, verbal orders,
transcribing errors and inadequate labeling (DH, 2004). Other causes identified include ‘look
alike and sound alike’ medications, equipment failure or malfunction, inadequate
abbreviations during prescribing, excessive workload, lapses and unavailability of
medications (DH, 2004).Medication Administration Essay
In a current literature review, two main types of medication errors were identified which
include preparation errors and administration errors (Agyemang and While, 2010).
Preparation error was then subcategorized as wrong dosage, dose omission, wrong drug/fluid,
wrong patient, wrong time, wrong form of medication, wrong solvent and unlabelled
medication containers. Administration error was subcategorized as administration rate error (
Agyemang & While, 2010). This is congruent with Pierson et al. (2007) who conducted a
survey of medication errors in 25 nursing homes in US and found that the most common
errors were dose omission, overdose, underdose, wrong patient, wrong product and wrong
strength. They concluded that errors most commonly occurred during medication
administration as a result of basic human error including high staff turnover, heavy use of
agency nurses, understaffing, and lack of communication between staff.Medication Administration Essay
2.7 Cost of medication errors
The personal costs of medication errors for patients may include suffering, the need for
additional treatment, loss of income, and death. Family members also experience emotional
trauma as a result of seeing a loved one suffer. For the estimated 1.5 million people who are
injured by medication errors each year in United State, health care facilities incur a
conservative estimate of $3.5 billion in additional expenses while treating their injuries. If
this dollar amount were extended to lost wages, lost productivity, and other additional
expenses, the costs associated with medication errors might increase to as much as $29
billion (Aspden et al. 2007). The UK Audit Commission estimate that the adverse events
associated with the use of medicines in the NHS cost £820 million per year and that this cost
trend is upwards (DH, 2004). This does not include the cost of litigation or of human
suffering associated with these events. If these estimates are extrapolated to the Irish
population it will amount to a potential cost of €54·6 million for extra bed occupancy alone.
To place €54·6 million in context this is almost half of the total amount of money spent by
Irish hospitals on drugs each year and it is more than double the amount spent on staffing the
pharmaceutical services in the hospitals (HSE, 2005).
In addition to the financial costs involved in medication errors, there are substantial costs to
the reputation of the health care profession and its members. Every time a medication error
occurs, whether it is reported by the media or whether the information simply is spread by
word of mouth, the public loses confidence in the quality of health care that is provided
(HSE, 2005).Medication Administration Essay
2.8 Medication error detection methods
There are several ways in which medication errors have been detected and an error rate
compiled. Schneider (2002) presented nine workshop vignettes on medication error detection
methods in hospitals. These nine methods ranged from the voluntary reporting method,
to chart review method, to the observation method, to using various computer-assisted
information technology methods. He concluded by stating that no single method offers a
comprehensive measure of medication safety, but rather a combination of methods needs
to be used. Furthermore, Flynn et al. (2002) conducted a study in which the observation,
chart review and incident report (self report) methods were compared in 36
hospitals and skilled nursing facilities in two cities. Results of the study revealed that the
observation method was far better at detecting the most common categories of medication
errors. Out of a total of 457 errors confirmed by a research pharmacist, 300 of 457 were
detected by observation method, 17 of 457 by chart review & 1 of 457 by incident report.
This is congruent with Barker et al. (2002) who concluded that direct observation is the
highly reliable in detecting large numbers of medication administration errors in in-patient
and long term settings.
2.9 Medication supply systems
Despite that medication management involves other health care professional- doctors and
pharmacists; it is an important part of the nursing role (ABA 2007). Nurses have the
responsibility of preparing the medication before administering it to residents (O’Shea 1999).Medication Administration Essay
In nursing homes, medications are supplied in different systems prior to being administered
by nurses. These include compliance aids/monitored dosage systems (Appendix 1) also
referred to as individual medication supply system or unit of use packaging. (Hodgkinson et
al. 2006); Lipowski et al.2002) and traditional bulk packaging (Lipowski et al. 2002).
Compliance aids are devices in which a resident’s tablets and capsules are packed into
separate compartments, usually four for each day corresponding to the doses to be taken at
mealtimes and bedtime. They are designed to assist residents to self administer their
medications (ABA, 2007). Examples are the dossette boxes and medidos (Ashurst, 1992).
Monitored dosage systems are based on a 28-day cycle. The tablets/capsules are individually
sealed into a blister pack divided into four columns and seven rows; each column represents 1
week and the rows represent the days of the week (Ashurst, 1992).
In contrast, systems used in the hospital settings include ward stock and computerized
system for example automated dispensing, bedside terminals, computer generated MAR, alert
systems and bar coding (Hodgkinson et al. 2006). These systems have been shown to reduce
costs while reducing medication error (Perras et al. 2009). Nonetheless, the nursing homes
sector lags far behind in the use of these technologies (Poon et al. 2006). But given the high
risk of medication error in long-term care (Pierson et al. 2007), there is need for
implementation of best practice in medication management in nursing homes.Medication Administration Essay
2.10 Best practice in medication management
Managing medication is a vast area that is governed by legislation and best practice. The
national standards for older people in residential care in Ireland arising from Health Act
(2007) as well as ABA (2007) guidance for nurses on medication management explicitly state
the responsibilities of the person in charge/nurse manager in relation to medication
management. Under Part 8, section 33 (1) and (2) of the Health Act 2007, it is required that
‘the registered provider shall ensure that the designated centre has appropriate and suitable
practices and written operational policies relating to the ordering, prescribing, storing and
administration of medicines to residents’ (p.19) and ‘the person in charge shall ensure that
staff are familiar with such policies and procedures’ (p.19). Additionally, the registered
provider is expected to ‘ensure that there are suitable arrangements and appropriate
procedures and written policies in accordance with current regulations, guidelines and
legislation for the handling and disposal of unused or out of date medicines and the person in
charge should ‘ensure that staff are familiar with such procedures and policies’ (p.19).
Similarly, ABA (2007) state that nurses exercising their professional accountability in the
best interests of patients must be sure to apply the five rights of medication administration i.e.
right medication, patient/service-user, dosage, form, time. On the contrary, Cox (2000)
argued that quality in medication administration is not simply a matter of adhering to these
five rights. This view was supported by Elliot and Liu (2010) who state that although seven
rights (the five rights plus right response and documentation) have been proposed, errors still
occur. Therefore, they went further to propose the nine rights(Figure 2) of medication
administration (right patient, right drug, right route, right time, right dose, right
documentation, right action, right form and right response).
Elliot and Liu (2010, Figure 2)
Furthermore, Elliot and Liu (2010) state that medication errors can take many forms, and may
occur at different phases of the medication administration process (from prescription by the
medical officer/transcription by the nurse, to dispensing by the pharmacist, or administration
by the nurse). To this end, ABA (2007) clearly set out best practice in medication
management i.e. from prescription/transcription all through to administration of medication.
They suggest that the responsibility for documenting the prescription/medication order is
with the medical practitioner and/or the registered nurse prescriber to prevent the possibility
of error by another individual and a nurse who transcribes is professionally accountable for
her/his decision to transcribe and the accuracy of the transcription(ABA, 2007). Several
strategies have been proposed in the literature to reduce prescription error including
computerized physician order entry (CPOE), use of medical administration record
(MAR)/electronic medical administration record (eMAR) (Hodgkinson et al. 2006) as well as
double checking mechanism where a nurse took on the responsibility of transcription (ABA,
In addition, it was recommended that medications should be dispensed by the pharmacist and
should only be undertaken by the nurse in exceptional circumstances (ABA, 2007). In order
to prevent dispensing errors, evidence suggests that technological systems, such as bar coding
of medicines, may offer real opportunities to reduce the level of dispensing errors as well as
independent check on dispensed medication by another professional colleague (Ashcroft et
al. 2005). ABA (2007) stated further that the nurse should observe the five rights in order to
prevent errors during medication administration but evidence has proved that the five rights
are not enough to prevent error ((Elliott & Liu, 2010). Therefore, other strategies have been
recommended, for example, ensuring that dosage calculations are checked independently by
another health care professional before administration, ensuring that prescription, drug and
patient are in the same place in order that they may be checked against one another,
minimizing interruptions during drug rounds by wearing red apron and adopting a non
punitive approach to error reporting (William, 2007). Furthermore, Cousins (1998) suggest
that in long term care settings (nursing homes), the most effective strategies to reduce
medication error include nurse education, physician education, changing the role of the
pharmacists to allow them become proactive in the medication management process and use
of automated systems.
2.11 Barriers to implementing medication safety
According to Greenall and David (2004), barriers to the implementation of medication safety
strategies in hospitals include a lack of specific planning, scarce resources, complacency, and
insensitivity to the inherent risks in the medication process. They state further that fear of
reprisal and personal relationship could be a significant obstacle to reporting incidents and
influence sharing and reporting information.
In a recent study conducted by Dille et al. (2011), identified barriers to implement medication
safety in nursing homes include being interrupted, not knowing enough on interactions, and
barriers to inter- disciplinary cooperation (informing, reporting, and the frequency of
communication), a feeling of lack of responsibility in monitoring medication effects and a
lack of time to double-check medication prior to administration.
2.12 Summary
In this chapter, the writer has defined and discussed nursing homes, medication error and
adverse drug events. In addition, types and causes of medication errors, different types of
medication administration methods, strategies to prevent medication errors and barriers to
implementing medication safety have been explored. It is worth noting that in nursing homes,
medication management has received comparatively little attention and the issues differ
substantially from the hospital setting because of the lower acuity, increased number of
medication, cognitive impairment and frailty of most residents (Hodgkinson et al. 2006)
Chapter 3
Change process
3.1 Introduction
Organizations are continually in the process of change, with the expectation of becoming
more productive, efficient, and effective in their goals and mission and effective management
of that change is an important competency currently required (Briody et al.2012). In this
chapter, various types of organizational change and change models will be discussed. The
writer will also discuss the change implemented using a blend of the plan-do-study-act cycle
and Kotter’s eight step model.
3.2 Critical review of approaches to change
Before delving into various approaches to change, it is important to examine the types of
change in organizations. Weick and Quinn (1999) categorized organizational change as either
episodic (infrequent and sometimes radical) or continuous (incremental, emergent, and
without end). According to Gilley et al. (2009) change may be further classified as
transitional- improvement of the current state through minor, gradual changes in people,
structure, procedures, or technology; transformational- change in culture, processes, structure
and strategy (Barr and Dowding, 2008); or developmental- improvement of skill and
processes (Burke, 2011). From performance improvement view point, change could be
classified as reactive- required to maintain the system in the current level of performance or
fundamental-needed to create a new system of performance (Langley et al. 2009).
Smith (2005) describe change as moving from an existing state of things to a new state and
according to Jones and Jenkins (2007) there are no one only solution for moving from the
existing state to a newly desired state, they suggest that change models/theories be used as a
guide to facilitate a successful change. Therefore, reviewing the literature, there are different
types of change models and many ways by which these have been categorized but the two
dominant ones are the planned and emergent change models (Burnes, 2005). Planned change
models focus on changes that are deliberately brought about by stakeholders who are
accountable for the organization’s operation (Lewis, 2011) while the emergent models focus
on changes that occur spontaneously in response to some unanticipated external factors
(Burke, 2010).
3.2.1 Planned change models
The planned change model assumes that structures, processes, technology and
human skills, capabilities, and knowledge can be changed to support or optimize the
achievement of identified strategic organizational goals (Gardner and Ash, 2003). These
models are subgrouped as follows:
Traditional model: This model could be referred to as the step model. From the 1950s to
early 1980s, models of change management followed a relatively simple step process that
included evaluating and preparing an organization for change, engaging in change, and
solidifying the change into the fabric of employees’ daily lives (Medley and Akan, 2008).
Lewin’s (1951cited in Barr and Dowding 2008, p.205) 3 step model, for example, consists of
unfreezing, moving and refreezing. Other examples are: Lippet et al. (1958 cited in Barr and
Dowding 2008, p.205) 3 phase model consisting of clarification or diagnosis of the problem,
examination of alternatives and establishing a plan of action and transformation of intention
into actions that will lead to change; Beckhard’s (1969 cited in Armstrong 2006, p.343-357)
4 stage model including setting goals and defining the future state or organizational
conditions desired after the change, diagnosing the present condition in relations to these
goals, defining the transition state activities and commitments required to meet the future
state, developing strategies and action plans for managing this transition in the light of and
analysis of the factors likely to affect the introduction of change; Thurley’s (1979 cited in
Armstrong 2006, p.343-357) 5 stage model which include ‘directive, bargained, hearts and
minds, analytical and action-based; Havelock’s (1973 cited in Barr and Dowding 2008,p.206)
6 stage model- Build relationship, diagnose problem, acquire resources, choose solution, gain
acceptance, stabilisation and self renewal ; Rogers’(1983cited in Barr and Dowding
2008,p.206) 5 stage diffusion of innovation model-Awareness, interest, evaluation, trial and
Contemporary Model: By the late 1980s to 1990s, theorists of organizational change suggest
more extensive, multistep frameworks that include leadership, employee involvement,
rewards, communication, and more (Medley and Akan, 2008). Examples are: Kanter et al.
(1992 cited in Burnes 2009, p.117)) 10 step model consisting of analyse the organization and
its need of change, create a shared vision and a common direction, separate from the past,
create a sense of urgency, support a strong leader role, line up political sponsorship, craft an
implementation plan, develop enabling structures, communicate, involve people and be
honest, reinforce and institutionalize change; Ulrich (1998) 7 step model which include
leading change, creating a shared need, shaping a vision, mobilizing commitment, changing
systems and structures, monitoring progress and making change last; Critics of these models
cite failure to recognize the complexity of change, simplistic assumptions of success should
one follow the rigid steps in order, failure to recognize the human factor, and lack of
preparedness for resistance, to name a few (Gilley et al. 2009).
3.2.2 Emergent change models
According to Yeo and Ajam (2010) this model is associated with learning process rather than
a method of change to influence organizational structures and practices. They further state
that it operates on the assumption that change is not linear but involves complexity and
ambiguity. With this view, leaders are seen as highly competent and adaptable, capable of
switching from being controllers and coordinators to facilitators and collaborators while
employees are believed to be willing to take responsibility for identifying deficiencies and
implementing change. These models could be sub classified as follows:
System model: The system concept views organizations as constantly interacting with their
environment. The organizational environment is comprised of a set of relationships between
agents or stakeholders and other factors that may be beyond the control of the organization
(Mason, 2007). Examples are: Pettigrew and Whipp (1991) model of strategic change which
suggests that there are five interrelated factors that are important in shaping organization’s
performance, namely, environmental assessment, human resources as assets and liabilities,
linking strategic and operational change, leading change and overall coherence (Shanley,
2007); Mckinsey’s 7s model of organizational change consisting of seven elements that
influences planned organisational change. They are: skills, systems, style, staff, shared
values, structure and strategy (Barr and Dowding 2008); Leavitt et al. (1973) fourdimensional systems model of change, namely, structure, technology, people, or task; BurkeLitwin (1992) model of organizational change consisting of external environment, mission
and strategy, leadership and culture, management practices, structure, systems, work unit
climate, motivation, individual needs and values, task requirements; Kotter (1996) 8 stage
process of leading change consisting of establishing a sense of urgency, creating the guiding
coalition, developing a change vision, communicating the vision for buy-in, empowering
broad-based action, generating short-term wins, never letting up and incorporating changes
into the culture.

Providing care for the patient is the responsibility of nurses. Nurses are the one who are close with patients. They are responsible and accountable to make sure that the treatments and needs of patient are fulfilled. Medication administration is a part of the nurses’ responsibility in order to make sure clients get the correct medication as supposed. Medication administration error is a universal health care concern.Thus the strategy in improving medication administration system is important to enhance safety. The administration of medication by nurses is the final step in a process that involves multiple …show more content…
On the other cases, the nurses do not follow the correct time for medication administration. For instance, they just merely combine the medication that should be given at 4p.m with 6p.m. In that case, the effectiveness and toxicity of medication can be query. Thus, medication error can be some way again linked to an inconsistency applying the six rights of medication administration.Medication Administration Essay
Definition of terms

Nurses A person educated and trained to care for the sick or disabled; One that serves as a nurturing or fostering influence or means (C.L.R James,2009 )

Working experience Linking of a period of activity in a work setting (whether paid or voluntary) to the programme of study,irrespective of whether the work experience is an integral part of the programme study (Harveyet al,2002)

Incident Any other incident in which researcher is unsure about exposure potential.

Medicines management can be defined as;

“…a system of processes and behaviours that determines how medicines are used by the NHS and patients.”

(National prescribing centre,2002, P1).

According to Dr Michael Dixon chair of the NHS alliance, Medicines management services are the processes for designing, implementing,

delivering and monitoring patient-focused care, based on need, and include all

aspects of supply and therapeutic use of medicines within healthcare settings.

“Poor medicines management within organisations can lead to low public confidence in health services, unaddressed health needs and unsatisfactory patient outcomes and can lead to unscheduled emergency admissions or failure to maintain independence in the community leading to re-admission to hospital and other acute care settings. It can also lead to organisational issues such as, unmet targets, inappropriate allocation of resources, inefficient services, and risk.”Medication Administration Essay

(Calderdale pct, 2004)

“Good medicines management means that patients receive better, safer and more convenient care. It leads to better use of professional time and enables practitioners to focus their skills where they are most appropriate. Effective medicines management also frees up resources which means that NHS money can be used where it is most effective. Good medicines management benefits everyone.” (

“Non-medical prescribing is prescribing by specially trained nurses, optometrists, pharmacists, physiotherapists, podiatrists and radiographers, working within their clinical competence as either independent or supplementary prescribers.” (

The Department of health recognised that non-medical prescribers are a large and growing workforce. They found that by the end of 2009 there were over 14,000 nurse prescribers, 1700 pharmacist and supplementary prescribers and many community nurse prescribers and allied health professional prescribers that had qualified to prescribe within their competence. (DOH, London, 2009).Medication Administration Essay

This piece of work is a case study of a service user from the authors practise placement area at the time of writing. The case study incorporates three key elements within it;

The service user
Three medications prescribed to them
The legal and professional issues surrounding the above
The case study will look at these three elements in detail within the report.Medication Administration Essay

(In order to uphold confidentiality, during this report the service user in question will be referred to as ‘Mary’. (NMC, Code, 2008)

Mary is a seventy three year old lady who was admitted to the inpatient practise placement area on the 02/04/2011. Mary has a diagnosis of Alzheimers Dementia and was presenting with increased confusion and according to her care givers (Mary was a resident in a nursing home) had been showing signs of depression and aggression over the last few months culminating in a series of aggressive outbursts which ended in a serious attack on a member of her care home staff.Medication Administration Essay The decision had been made that a hospital admission to the organic illness assessment ward (Older people’s services) was necessary to manage risk, assess the progression of Mary’s condition and reassess her package of care. Mary was initially resistant to all interventions from the ward team and displayed high levels of agitation and aggression. The consultant and nursing team felt that medication would play an important role in the management of Mary’s initial presentation. However Mary’s resistance to any therapeutic interventions meant that alternative approaches were felt to be the only option at the start of treatment. John was also given a capacity assessment and found to lack capacity which allowed the ward staff to treat Mary effectively in her best interests.Medication Administration Essay

(For Mary’s pen story see appendix 1)

Mary has a diagnosis of Alzheimers Dementia.

The Alzheimer’s society explain the term dementia describes a group of symptoms these include a decline in memory, reasoning and communication skills a gradual loss and decline in the skills needed to manage the individuals activities of daily living , confusion and a change in behaviour or personality. These symptoms are caused by the physical impact of disease or injury on the brain. There are a number of different conditions that lead to dementia including Alzheimer’s disease.Medication Administration Essay


“Making a diagnosis of dementia is often difficult, particularly in the early stages The time it takes to make a diagnosis can vary. If scans and other investigations are required, it could be 4-12 weeks. If the person is in the early stages of dementia, a 6-12 month period of monitoring may be required before a diagnosis can be made.”


“The Mini Mental State Examination (MMSE) is the most commonly used test when a diagnosis of Dementia is being considered The MMSE is the test that the National Institute for Health and Clinical Excellence (NICE) recommends for deciding whether a drug treatment for Alzheimers Disease should be prescribed.”


However NICE do stress it should not be relied on as the only means of assessment alone as diagnosing dementia involves careful monitoring and assessment.Medication Administration Essay

“Treatment for Dementia should only be initiated and supervised by a specialist experienced in the management of Dementia.” (BNF, 2009, P280)

“Being prescribed a medicine is arguably the most frequent intervention in the NHS” (Shepherd, 2002).

Mary’s medication was reviewed on admission to the inpatient ward due to her aggressive and volatile presentation. For the purpose of this report three of the medications Mary was prescribed will be discussed in detail.Medication Administration Essay

“Acetylcholinerase inhibiting drugs are used in the treatment of Alzheimers disease, specifically for mild to moderate disease.” (BNF, 2009, P280)

Galantamine is a medication used to treat moderate Alzheimers dementia disease. Alzheimers occurs as a result of atrophy of the cerebral cortex. The disease causes changes in central neurotransmitter function especially the cholinergic system. It is linked to a lack of sufficient acetycholine levels. Evidence also points to raised levels of glutamate (a neurotransmitter).Medication Administration Essay

Galantamine is one of the centrally acting inhibitor of acetylcholinerase. It is a reversible acetylcholinerase inhibitor medication which works by increasing levels of acetylcholinerase in the synaptic cleft of central nervous system neurons. Galantamine is used to ‘slow’ neuronal degeneration by impeding further atrophy of the cerebal cortex. Evidence for the drug relates to an individual’s cognitive enhancement, however there is no cure for Alzheimers dementia and so medication is purely palliative. (Aarbakke, J et al, 2006)

Interactions of Galantamine from a patient safety perspective include:-

Warfarin effects are enhanced.
Antipsychotics and barbiturates effect is reduced (Johns dose of Zuclopenthixol increased to counteract this)
Muscle relaxants effects are modified.
Dosage of Galantamine must be carefully considered and the individual’s renal functioning and Creatinine levels must be checked prior to treatment.Medication Administration Essay

Side effects of Galantamine include:-

Sleep disturbance
Drowsiness and fatigue
Depression (Treated with Mirtazapine in Mary’s case)
(BNF, 2009, P281)

Mary was prescribed Galantamine Hydrobromide (Reminyl XL) a prolonged release medication. The Scottish medical consortium state Reminyl XL is recommended for the treatment of moderate Alzheimers dementia and allows a reduction in dose frequency and is as cost effective as immediate release forms of Galantamine. (

Mirtazapine is a medication used to treat depression. Theories explain the cause of depression as a neurobiological change resulting in too little Noradrenaline and 5HT in some central nervous synapses. Mirtazapine is an Atypical antidepressant. It is a presynaptic alpha2 adrenoreceptor antagonist and increases central noradrenergic and serotonergic neurotransmission which then increases the release of noradrenaline. Mirtazapine has an antihistamine effect with sedative effects and so is beneficial to Mary due to her agitation and restless presentation. Mirtazapine is also suitable for older adults due to its anticholinergic effect. (Aarbakke, J et al, 2006)

Interactions of Mirtazapine from a patient safety perspective include:-

Alcohol – Sedation increased
Warfarin – Enhances anticoagulant effect
Anxiolytics and hypnotics – Sedation increased. Mary is also prescribed Lorazepam at present and this is monitored closely when given for over sedation.
Withdrawl from Mirtazapine must be staggered due to side effects of withdrawing. (

Dosage – Mary is on a titrating dose of Mirtazapine and so may be experiencing side effects which she is not used to and may cause her further distress. It was important that Mary be monitored closely and reassured during this time.Medication Administration Essay

Side effects of Mirtazapine include:-

Increased appetite and weight gain (regular weight assessed and diet chart commenced)
Sedation (Mary is monitored closely for over sedation due to her other medications sedative effects)
Dizziness and headache
Postural hypotension (Mary’s blood pressure is checked daily)
“Mirtazapine causes few antimuscarinic effects and is therefore recommended over Trycyclic antidepressants” (BNF, 2009, P215).

Lorazepam is an Anxiolytic. Benzodiazepine anxiolytics are indicated for use short-term in anxiety states. However they are also used as an adjunctive therapy at the beginning of anti-depressant treatment to ease the initial worsening of symptoms, as in Mary’s case.Medication Administration Essay

Interactions of Lorazepam from a patient safety perspective:-

Respiratory Depression- (Mary was monitored and physical obs taken post dose)
Sleep apnoea syndrome (Mary was on arms length observation levels anyway)
Severe hepatic impairment
Myasthenia Gravis
Side effects of Lorazepam include:-

Hypotension (Mary’s bp was taken on a daily basis)
Confusion and Ataxia may be particularly apparent in elderly and should be closely monitored. (BNF, 2009,P189)

Therapeutic interventions which involve the prescribing and administration of medications have legal, professional and ethical implications. In Mary’s case these included the following issues.Medication Administration Essay

One of the problems with medication administration as part of planned care was Mary’s resistance to all interventions from the ward staff.

“People with dementia often have problems taking prescribed medication. They may forget to take it without prompting or supervision, and can lack awareness of their health problems. Some believe they do not need medication as they think there is nothing wrong with them.” (Stapleton, L. 2010)

Medication adherence can be improved by applying some simple measures:-

Ensure patients know what drugs they are taking, why they are taking them, and when. Also check that they are aware of any possible side effects, and what to do if they experience them.
Check that all patients with dementia are able to take their medication safely by organising dosette systems, and ensure carers can help patients where necessary.Medication Administration Essay
Give all patients and their families’ information about how to contact the clinic nurse by providing verbal information and written leaflets.
Ensure patients have a written treatment plan.
(Stapleton, L. 2010)

According to Cheesman (2006), adherence is an approach to achieving the best use of medication involving the sharing of information between healthcare professionals and patients. The prescriber can promote an effective therapeutic relationship by building a patient’s confidence in their ability to self-manage their condition.Medication Administration Essay

“The Mental Capacity Act 2005 provides a statutory framework to empower and protect people aged 16 and over who lack, or may lack, capacity to make certain decisions for themselves because of illness, a learning disability, or mental health problems. The act was fully implemented in October 2007 and applies in England and Wales. If someone is unable to make a decision for themselves at the material time because of an impairment of the mind, then that person can be said to lack the mental capacity to make that decision.” (Alzheimers society, 2011).Medication Administration Essay

According to the law, a person is defined as being unable to make decisions for themselves if they are not able to undertake at least one of the following:Medication Administration Essay

understand information given to them
retain that information long enough to be able to make a decision
weigh up the information available to make a decision
communicate their decision by any possible means, including talking, using sign language, or even through simple muscle movements such as blinking an eye or squeezing a hand. (Rethink, 2010)
Mary was found to lack capacity as she was unable to retain or weigh up the information given to him to make a decision. Mary lacked any insight into her recent worsening of symptoms, changes in behaviour and aggression. This is often the case with dementia disease.Medication Administration Essay

“The act encompasses five main principles:

1 A presumption of capacity − Every adult has the right to make their own decisions and must be assumed to have capacity to do so unless it is proved otherwise.
2 The right for individuals to be supported to make their own decisions − All reasonable help and support should be provided to make their own decisions.
3 It should not be assumed that someone lacks capacity simply because their decisions might seem unwise or eccentric.
4 If someone lacks capacity, anything done on their behalf must be done in their best interests.Medication Administration Essay
5 If someone lacks capacity, before making a decision on their behalf, all alternatives must be considered and the option chosen should be the least restrictive of their basic rights and freedoms.” (Warren, L. 2010)
“When considering a person’s views and wishes it is important that they are given weight, and are carried out, unless the effects would be detrimental to that person.” (National archives, 2010)

The multi-disciplinary team worked to all these principles in Mary’s case by:-

1. Presuming capacity by letting Mary make decisions until the capacity assessment had been done and a formal plan of care put in place. Mary was also supported to continue to make decisions on a daily basis which she was deemed to have capacity to make e.g. what to wear that day.Medication Administration Essay
2. Support was provided in the form of an Independent mental health advocate (IMHA).
3. Mary was found to have capacity to make certain decisions even if they seemed strange to the ward staff. Staff supported her in this.
4. Mary had a best interest assessment and the findings were used to formulate a comprehensive care plan for Mary.
5. The MDT sought input from the deprivation of liberty safeguarding team (DOLS) around the intervention decisions with Mary to ensure they were applying the least restrictive care.
When working with people with dementia ethical practise should be considered as dementia is a long-term illness with no cure. Treatment is purely palliative and the evidence for the benefit versus drawbacks to treatment is not fully understood.Medication Administration Essay (

Foot Anstey solicitors explain that Advance directives and lasting power of attorneys put in place can ensure that the service user receives the treatment and care they want when they are no longer able to voice their requirements themselves. (

Healthcare professionals must make the service user the centre of care decisions in the service user’s best interests to uphold ethical practise.Medication Administration Essay